PPH Flashcards
What is a PPH?
Defined as excessive bleeding from the genital tract occur at any time from the birth of the baby to the end of the puerperium. It is a significant cause of maternal mortality and morbidity
(Mayes 2012)
What are the types of haemorrhage?
Minor PPH = 500-1000mls Major PPH = greater than 1000mls Types of major haemorrhage: Moderate = 1000-2000mls Severe = 2000mls (RCOG 2016)
Primary PPH
Occurs in the first 24 hours after delivery and is the most common and dangerous type
(Mayes 2012)
Secondary PPH
Occurs after 24 hours and before the end of the puerperium and affect approximately 2% of all deliveries
(Mayes 2012)
Incidence of PPH
Occurs in approximately 5-10% of all deliveries
MBRRACE reports on haemorrhage
MBRRACE (2018) reports that 18 women died of haemorrhage between 2014-16. It is the leading cause of maternal death worldwide
What is the normal adult blood volume?
70mls/kg, which is a total volume of about 5 litres. This increases in pregnancy to approximately 100mls/kg which is about 6-7 litres in a healthy pregnant women.
(Prompt 2017)
Antenatal risk factors for PPH
- Previous retained placenta or PPH - Maternal Hb level below 85g/l at onset of labour - BMI greater than 35 - Grande multiparity - APH - Over distention of the uterus (e.g. multiple pregnancy, polyhydramnios or macrosomia) - Existing uterine abnormalities - Low-lying placenta - Maternal age of 35 or more (NICE 2017)
Intrapartum risk factors for PPH
- Induction
- Prolonged first, second or
third stage - Oxytocin use
- Precipitate labour
- Operative birth or CS
(NICE 2017)
What to do if a women has risk factors for a PPH?
- Should be highlighted in her notes and a care plan covering the third stage (NICE 2017) - MBRRACE (2016) report advises that actively managing the third stage helps prevent PHH for those at risk - Avoid routine episiotomy (MBRRACE 2017) - Intravenous cannula should be advised and blood samples taken including haemoglobin (Mayes 2012)
Potential complications of PPH
- Severe anaemia
- Pituitary infarction
- Coagulopathies
- Renal damage
- Coma
- Death
Causes of PPH
Tone - uterine atony (70%)
Trauma - genital tract, lacerations, haematomas, ruptured or inverted uterus (20%)
Tissue - retained placenta, placental products and blood clots (9%)
Thrombin - blood coagulation disorders (1%)
(Mayes 2012)
Clinical signs of severe blood loss
- Rapid, weak pulse (>140bpm) or bradycardia (<60bpm) - Severe hypotension (<70 mmHg) - Pallor, cold clammy skin, peripheral cyanosis - Air hunger - Anuria - Confusion or unconsciousness, collapse (Prompt 2017)
Mnemonic for what to do when PPH occurs
Cat = call for help Runs = reassure Into = IV access Box = bloods
Oh no = oxygen
Cat = contraction
Falls = fluid resuscitation
Through = trendelberg
position
Cat = catheterise Obviously = observations Dies = documentation
IV access
At least two large bore (grey) intravenous cannulae should be sited as soon as possible.
(Prompt 2017)
Bloods taken once IV access established
Full blood count Renal function Clotting (including fibrinogen) Cross matching (Prompt 2017)
What are the first line choice for early fluid replacement?
Crystalloid solutions
e.g. Hartmann’s solution or 0.9% sodium chloride
(Prompt 2017)
Why do warmed fluids need to be infused as rapidly as possible)
To restore the systolic blood pressure
Prompt 2017
Volume of fluids to be infused
Aim to maintain normal plasma volume - 2 litres of warmed crystalloid should be administered immediately. If bleeding continues, consider infusing up to a further 1.5 litres of crystalloid if blood product not available
(Prompt 2017)
When to give blood?
Although needs to be consider carefully when there is a major haemorrhage, it is preferable to transfuse fully cross matched blood as soon as possible. However, if fully cross matched blood is not available after 2-3.5 litres of fluids, or if bleeding is unrelenting, O negative or type specific blood should be given
(Prompt 2017)
What does transfusing a ‘unit of blood’ do and what else should be given?
Only replaces red blood cells and does not replace clotting factors or platelets. Therefore early consideration should be given to transfusing fresh frozen plasma, cryoprecipitate and platelets.
(Prompt 2017)
How much fresh frozen plasma should be given?
RCOG recommends that up to 15ml/kg (approximately 4 units) for every 6 units of red blood cells
(Prompt 2017)
How much cryoprecipitate should be given>
Up to 2 packs of cryoprecipitate (10 units) can be given while clotting results are awaited
(Prompt 2017)
Fibrinogen during PPH
Is a vital coagulation factor and low levels during obstetric haemorrhage are associated with increased bleeding. Recent guidelines recommend replacing fibrinogen with either cryoprecipitate or fibrinogen concentrate during obstetric haemorrhage to maintain maternal plasma levels above 2 g/l
(Prompt 2017)
Who do you need to call for help?
- Midwife in charge
- An additional experienced
midwife - Experienced obstetrician
- Experienced anaesthetist
- Experienced paed
- Alert consultant
haematologist - Inform blood bank
(Prompt 2017)
Maternal position during PPH
Lie the women flat (Prompt 2017)
Can also consider the trendelenburg position where the head is tilted down and the legs are raised up.
What is the immediate action when you have identified a PPH?
Call for help while rubbing up a contraction
Mayes 2012
Why massage the uterus?
Will usually stimulate a contraction and expel any blood clot
(Mayes 2012)
What procedure should you do if bleeding continues after rubbing up a contraction?
Bimanual compression
Prompt 2017
What should be done as the women is being laid flat?
High flow facial oxygen through a non rebreathe mask
Prompt 2017
What observations are required and at what time intervals?
Pulse (continuous using a pulse oximeter) O2 sats (continuous) BP (continuous using automated machine) Resps Temp (every 15 minutes)
What drug should be given if the third stage has not been actively managed?
Either administer 10 IU of oxytocin IM
or
Syntometrine 1ml IM
(NICE 2017)
What drug should be used in the third stage for women having CS?
Oxytocin 5 IU IV by slow injection
NICE 2019
By how much does active management reduce the risk of PPH?
Reduces the risk by 60%
NICE 2017
What drugs should be given if active management third stage drugs have been given and the bleeding is continuing?
Give a second dose of oxytocin -
10 IU IM
or if syntometrine used 1ml IM
(Prompt 2017)
What does syntometrine consist of?
5 units of oxytocin and ergometrine 500 micrograms
Prompt 2017
What PPH drug is contraindicated in hypertensive women?
Ergometrine (thus syntometrine) because it raises BP as a side effect
When should bolus dose of IV oxytocin be used with caution?
When there is extreme maternal hypotension as can cause a further fall in BP
(Prompt 2017)
If the first line oxytocic medication causes the uterus to contract, what should you then do to maintain uterine tone?
Commence an oxytocin infusion -
Oxytocin 40 units diluted in 500ml 0.9% sodium chloride and infuse via infusion pump at 125 ml/hour over 4 hours
(Prompt 2017)
What to do if after the intravenous infusion of oxytocin the bleeding has not stopped?
Administer carboprost (hemabate) 250 micrograms IM injection. Repeat if necessary at intervals of not less than 15 minutes to a maximum of 8 doses (2mg). Should be used with caution with women with asthma. (RCOG 2016)
What drug should be considered if carboprost is unsuccessful?
Misoprostol 800 micrograms rectally or sublingually
RCOG 2016
Tranexamic acid dosage
1g given as a slow IV injection at a rate of 1ml/minute
If the bleeding continues after 30 minutes of restarts within 24 hours of the first dose, then a second dose of 1g can be given
(Prompt 2017)
Evidence for tranexamic acid
A cochrane review found that women who received tranexamic acid has less common blood loss greater than 400 or 500 ml after vaginal birth or CS. It was effective in decreasing the incidence of blood loss greater than 100ml in women who had undergone CS but not vaginal birth. Further studies are needed
(RCOG 2016)
What does tranexamic acid do?
An antifibrinolytic which prevents the breakdown of fibrin deposits at bleeding sites in the body. However it does not stimulate uterine contractions
(Prompt 2017)
Signs of shock
- Maternal tachycardia of more than 100 bpm - Resp rate of over 30 breaths per minute - Peripheral vasoconstriction meaning a capillary refill greater than 2 seconds (Prompt 2017)
How to identify the cause of a PPH?
- Check whether the uterus is well contracted - Check that the placenta has been expelled and is complete - Examine the cervix, vagina and perineum for tears - Observe for signs of clotting disorders, such as oozing from wound and cannula sites (Prompt 2017)
Why catheterise the bladder?
A full bladder can inhibit effective contraction of the uterus. Insert an indwelling Foley catheter to empty the bladder. Note the amount drained and monitor further urinary output hourly as an indicator of renal function
How do you do bimanual compression?
Insert one hand into the vagina and form a fist. Direct your fist into the anterior fornix and apply pressure against the anterior wall of the uterus. With the other hand, press externally on the uterine fundus and compress the uterus between your hands. Maintain compression until bleeding is controlled and the uterus contracts
(Prompt 2017)
What should be done with identified tears?
Apply pressure and repair
Prompt 2017
What is the most common cause of persistent uterine atony?
Often cause by retained placental tissue or blood clots. Exploration and emptying of the uterus should be performed as soon as the mother has been resuscitated
(Prompt 2017)
What are some surgical measures that can be taken to try and manage a PPH?
- NICE (2017) adivse to n consider a balloon tamponade before surgical options which remained in situ for 24 hours - B Lynch sutures are absorbable sutures which are inserted through the thickness of both uterine walls to compress the uterus - Pelvic vessel ligation is if all other methods have failed, arterial ligation will be necessary. - Every attempt to conserve the uterus will be made but if these measures fail to control the bleeding, a hysterectomy is necessary to save the women's life (Mayes 2012)
What do RCOG guidelines state about hysterectomy?
To resort to hysterectomy sooner rather than later and ideally a second clinician should be involved in the decision
(RCOG 2016)
What information needs to be documented throughout the emergency?
- events
- timings
- fluids/drug given (timings
and doses) - observations (including
MEOWS)
(Prompt 2017)
